Vail Vitrectomy: Controversial Elitism or Educational Masterpiece?

In the spring of 1975, Robert Machemer, MD, and a
handful of early vitrectomy pioneers launched a retinal
surgery meeting series in Vail Colorado called the Vail
Vitrectomy meeting. The mid-1970s marked the heyday
of vitreous surgery evolution. Everything was new, no
fellowships existed, and new concepts were being developed.
Instrumentation was being invented, and, often,
these new instruments were tried first in patients rather
than in animals, resulting in an abundance of surgical
complications. Although many eyes were saved, countless
others were being blinded. Because many eyes were
indeed being helped, however, enthusiasm for this new
technique, vitrectomy, was at fever pitch.

As with any new scientific endeavor, the ability to
think outside the box was a great driver of thought. Dr.
Machemer, always a visionary, recognized that a powerful
way to facilitate ideas was to pull together a select
group, seal them together in a retreat-like atmosphere,
encourage out-of-the-box thinking, and protect the discussions
from premature dissemination. And the concept
worked. The early Vail Vitrectomy meetings were exciting
and facilitated fruitful think-tanks. The luminaries who
attended those meetings included Tom Aaberg Sr., Ron
Michels, Steve Charles, Nick Douvas, Steve Ryan, Helmut
Buettner, Buzz Kreiger, and Jay Federman, among others.
Although each of these great names in vitreous surgery
has contributed individually to the evolution of our craft,
the ability to bring them together in 1 room served to
create a chemical reaction of ideas. From that chemical
reaction emerged an explosion of innovation in techniques
for vitreoretinal surgery.

The Design of Vail Vitrectomy

Dr. Machemer believed that if he was to create
this vibrant chemical reaction of ideas, he had to
add together the right ingredients, namely by pulling
together people who might be the best to facilitate this
thought reactor. For that reason, he initiated the most
controversial aspect of the Vail meetings: its invitationonly
exclusivity. Dr. Machemer knew that vitreoretinal
surgeons had a variety of disparate research interests
and talents. It was his goal to capture those individuals who at that time were active solution seekers. If
too many people were allowed to attend, he thought,
discussion would be stifled. Recognizing that the discussion
of a presentation is often more important than
the presentation itself, he wanted to ensure that the
right number of people was present, and that each person
truly had ideas to contribute. This was not a forum
to teach, but rather a forum to learn. In the early days
of the meeting, this concept worked.

Attendees of the Vail Vitrectomy meeting were
required to present a paper on a topic that had never
been presented before at a prior national or international
meeting (see inset, Past Vail Vitrectomy Presentations).
That requirement continues today, with the hope that
the program will showcase the latest, state-of-the-art of
ideas. Some of the ideas presented at the Vail meetings
over the past 35 years have been real game-changers.
Other ideas have been found to be unnecessary or outright
wrong. Through it all, however, the craft of retinal
surgery has continued to evolve, and the Vail meetings
served as an important source of ideas.

To be invited to the Vail Vitrectomy meeting was
perceived as a mark of distinction. At 1 level, it was Dr.
Machemer’s stamp of approval in that you were worthy
of being selected to attend this exclusive meeting. At
another level, it was membership into an elite group of lecture-circuit speakers. And to some, it was an insult not
to receive an invitation.

First-hand Perspective
on Vail Vitrectomy

I remember receiving my first invitation to attend the
meeting in 1991, being only 6 years out of my fellowship.
I thought, “Wow, I made it! I can’t believe Robert
Machemer knows who I am.” Attending the meeting
was a mix of emotions, as I was in awe of meeting many
of the people in the room. Watching Ron Michels and
Steve Charles argue was extraordinary, understanding
the enormous breadth of thought and expertise that
each possessed. I was a bit frightened too, hoping that
my comments and presentation would be worthy of
the meeting’s purpose. After giving my presentation,
which involved a video presentation of vitreous surgery
as viewed from the inside of the eye in high magnification
of the pars plana, I wondered if it had passed the
Machemer test. When Dr. Machemer came to me
at the break, and asked if he and I could have lunch
together because he was fascinated by my talk and
wanted to learn more, I felt that I was on my way to
being a contributor.

My next moment of worry came 4 years later, wondering
if I would be invited back to the next Vail meeting.
The letter arrived. I knew, however, that if I expected
to continue to play in the majors, I had to make sure
that every talk I gave at this meeting was at the highest
level. Although I take seriously any presentation I give
at any meeting, I knew the Vail meeting was special. It
had to be my best.

Controversies of Vail Vitrectomy

The exclusivity of the invitation-only format of the
meeting has been a point of great controversy over
the years. To be left off the invitation list was often
very upsetting. After all, what right did Dr. Machemer
have to determine who was worthy of attending? If
you were in private practice, were you held in the same
regard as those in university employ? If you were doing
great research that had not yet reached the eyes of the
organizers, it seemed unfair to be excluded. Politics was
involved. Some surgeons who were no longer at the top
of their game were still being invited. If you ever had
criticized the wrong person or idea in public, you might
be blacklisted.

So why does the Vail Vitrectomy meeting continue as
an invitation-only event?

All meetings are not the same, and thus cannot serve
the same purpose. In the early days of the Vitreous Society
(now American Society of Retina Specialists) meetings,
the events were small, allowing great discussions at the
microphone. Everyone was allowed to talk, no matter
what one’s background or source of employment. Now,
the meeting has become so large that it has evolved,
making intimate discussions of each paper difficult. The
American Academy of Ophthalmology subspecialty
meetings are so large that discussions of each paper are
impossible. And yet, each meeting serves a niche.

The Vail Vitrectomy meeting was designed to bring
together people who have demonstrated that they are
trying to think out of the box. In order to maintain
the ability to foster discussion—the most important
aspect of the meeting—the number of people in the
room must be limited. For the Vail meeting to have
500 attendees would destroy its raison d’être. Even
with that realization, it has been very difficult to keep
the Vail meeting at a manageable level. The number of
those invited has slowly enlarged over the years in large
part to avoid leaving deserving people off the list.

Since Dr. Machemer’s retirement from the meeting
in 1996, the designation of invitees has been by committee
and has involved an international panel for the
selection process. Serving on the organizing committee
now for 2 cycles, I can tell you that it is one of the most
difficult duties I have had to perform. Although it is the
committee’s hope to capture the best and the most
innovative surgical minds, it is not an attempt to offend
or exclude anyone. It is recognized that some egos will
be bruised in the process, and that will always be unfortunate.
But not every truly talented athlete can play in
every game.

The abstracts and summaries from the Vail Vitrectomy
meetings are not published or disseminated publicly, and
these are also sources of controversy. Why are the talks
kept secret? Is it a desire to hold the information to only
a select group of people and hide it from the practicing
retinal surgeon who might benefit from the information?
An important aspect of the meeting is the desire to keep
the presentations new and at the start of the scientific
design. Because the material has never been presented or
published, it is felt that the information typically is not
yet ready for prime time. Knowing that the discussion
will not be published also opens up the floodgates for
critique during the meeting. In all, it allows for the best
evolution of the ideas, assisting in the natural selection
of the thought process, hoping that those ideas that do
have merit will find their way into the public eye in a
timely manner.

Looking Ahead: Vail 2013

The upcoming Vail Vitrectomy meeting has introduced
several new aspects in an effort to continue to serve the Vail philosophy, but to do it as fairly as
possible. A group of senior surgeons that has been
selected as “Vail Thought Leaders” will be invited to
attend but without the requirement of having to present
a paper. They will be there to participate in the
discussions, recognizing their enormous contributions
to the fund of knowledge of retinal surgery in the past.
Not only will this help keep the paper discussions lively
and at the highest level, but it also opens more spots
on the podium to allow more invitations. Also, for the
first time, a Call for Papers is being introduced, opening
up the meeting for those not initially invited to submit
a topic title and brief description. The committee will
review the submitted papers and extend a number
of additional invitations. In this way, young, possibly
unknown surgeons with great ideas will have a chance
to attend. More new ideas will be introduced, and the
think-tank will thrive even more.

The structure of the Vail meeting will likely always
be controversial. It is not perfect, but its design has a
carefully metered purpose. Its invitation-only structure
pushes attendees to give the meeting their best, and
the fact that the meeting is held only every 3 to 4 years
further brands its importance. The upcoming meeting’s
invitation list is lengthy and attempts to bring together
surgeons from around the globe. More than 60% of
those invited are from outside the United States. More
than 10% will be first-time invitees.

If you receive an invitation to Vail Vitrectomy 2013,
we hope you will attend and actively participate in the
process. If you are not on the initial list and would like
to present a topic for consideration, we invite you to
submit your topic title and brief description via the
Vail Vitrectomy Call for Papers process. To obtain more
information on paper submission, send an email to vailvitrectomy@
medconfs.com.

Dr. Machemer was a visionary in his concepts on
vitreous surgery, as he was with the creation of the
Vail Vitrectomy meeting. It is hoped that the next meeting
will ultimately result in at least a handful of new
ideas and concepts that will become game-changers
for the field.

Kirk H. Packo, MD, FACS, is Professor
and Chairman of the Department of
Ophthalmology at Rush University Medical
Center in Chicago, where he also serves as
Director of the Retina Section, and is cofounder
of the medical center’s Fellowship in Vitreoretinal
Surgery. Additionally, Dr. Packo is a senior partner with
Illinois Retina Associates. Dr. Packo can be reached via
email at Kirk_Packo@rush.edu.

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About Retina Today

Retina Today is a publication that delivers the latest research and clinical developments from areas such as medical retina, retinal surgery, vitreous, diabetes, retinal imaging, posterior segment oncology and ocular trauma. Each issue provides insight from well-respected specialists on cutting-edge therapies and surgical techniques that are currently in use and on the horizon.